This document provides background on the 2010 BP Deepwater Horizon oil rig explosion in the Gulf of Mexico. It identifies three major issues that contributed to the disaster: 1) BP's weak safety culture that prioritized cost-cutting over safety, 2) BP's risk-seeking culture that led them to cut corners and take unnecessary risks to meet tight budgets and deadlines, and 3) a lack of ethical values and proper risk management processes. The document will analyze solutions to address these issues and make recommendations to help prevent future disasters.

1. Columbia Gas of Massachusetts – Project Issue Analysis
It was late in the afternoon of September 13, 2018. Professor
Rich Maltzman looked up, startled, as three sharp raps on his
car window interrupted the online course he was teaching from
his car. Why from his car? Everyone in the town of Andover
(Massachusetts, USA) had already been told to get out of their
their homes, and they awaited word from the police – should
they leave the town altogether?
Yes! The three raps were from the Professor’s wife, and she was
animatedly and urgently conveying the message: “we have to
LEAVE TOWN. NOW!”
The urgency was coming from the breaking story so well-
summarized by the podcast series, “Fire in the Valley”. Fires
and explosions were occurring in over 100 structures in the
Merrimack Valley region of Massachusetts, north of Boston, in
particular in the City of Lawrence and the towns of North
Andover and Andover, Massachusetts, where the Professor and
his family reside.
It was hard for residents to get the important details. Local
news stations were covering the story, but the information was
scattered and hard to decipher meaningfully. The Twitter feed
from Columbia Gas of Massachusetts, the utility that operates
the natural gas lines that were involved had this post on their
web page for hours during the incident:

2. This was of little help – and if it wasn’t so sad, it would
actually be funny.
The local police were doing a better job posting advice and
making announcements and sending out reverse 911 calls to
residents. This is what triggered the raps on the windows and
yielded the decision for Professor Maltzman to prematurely end
his class, which ironically was about qualitative decision
making.
This tweet from the authorities made things much more clear:
What happened here?
So, the Professor and his family headed to Cape Cod to stay
with relatives – they were very lucky to have this option
available. Others were not so lucky. See this videofrom Rabbi
Howard Mandell who tells his story, which starts with a 6- foot
flame emanating from his boiler’s gas supply.
A tremendous write-up of the story comes from an article from
the June, 2019 issue of Popular Mechanics – an article entitled,
“The Day the Town Blew Up”.

3. Here the key extract:
…On the Salem Street side of the O’Connell South Common (in
Lawrence, Massachusetts), a public park, a contractor removes a
length of cast-iron pipe, caps it, and sets it aside.
Feeney Brothers Utility Services (“Providing Underground
Utility Services since 1988”) has a permit to open up a two-
foot-wide, 340-foot-long stretch of Salem Street, for the
purpose of “completing gas main tie-ins and retirement of dual
cast-iron gas mains.” Feeney Brothers is a family-owned
operation with seven hundred employees. They’ve worked
extensively not only for Columbia Gas but also for the region’s
other major natural-gas supplier, Eversource. In recent years,
gas utilities in Massachusetts have increasingly relied on
contractors to carry out projects like this.
It’s usually cheaper.
The job today is to install new polyethylene pipeline and tie it
into a new distribution main, also plastic. The Feeney Brothers
contractor may or may not be aware that a regulator sensing
line— a gauge that measures gas pressure—is attached to the
pipe he had discarded. But it’s important to note that he and his
crew are performing their duties as directed, under Columbia
Gas supervision, and correctly following the steps in the work
package Columbia Gas developed and approved. Columbia
Gas’s work order doesn’t mention the sensor and was not
prepared by a professional engineer. Until four years ago, a
technician from the Meter and Regulation Department would
have been assigned to the site to monitor pressure readings on
the affected section of gas main, but Columbia Gas, for
undisclosed reasons, has ended this practice.
The sensor on the discarded length of pipe thinks it’s still
measuring the gas pressure in a vast underground network. In
fact, it is measuring nothing: The pipe has been disconnected
from the network. The sensor might as well be attached to a hot
dog. But the sensor doesn’t know any of that, and there is no
other sensor in this segment of the network to contradict it.
The sensor sends a message to the regulator valves in this

4. segment of the network: Boost the pressure! Which they do. But
the sensor, because it’s still attached to the dead piece of pipe,
doesn’t detect any of that. Instead, it registers a pressure drop,
all the way down to 0.01 psi. More pressure, it tells the valves,
until they have opened completely, and two distribution systems
that were supposed to be segregated, cordoned off from each
other, are instead tied directly into each other for twenty-six
minutes.
A wave of high-pressure gas rushes into the regional gas-main
system that serves Lawrence, Andover, and North Andover. In
the older cast-iron segments of the network, the pressure rises
to at least 6 psi, twelve times what the pipes are capable of
handling.
At 4:04 p.m., the first high-pressure alarm is received by the
NiSource monitoring station—in Columbus, Ohio. A second
alarm is received at 4:05 p.m.
In the control room in Ohio, the NiSource employees have no
capacity to control, let alone shut down, the gas flow. They can
only contact the Meters and Regulations Group at Columbia
Gas, which at 4:06 p.m. dispatches its entire team of inspectors
to investigate—a total of two people, or approximately one per
2,494.75 miles of pipe.
The result of this over-pressurization: 141 fires, 5 explosions,
21 serious injuries, 1 death, many people displaced and/or
without heat or the ability to cook - for months, and the
bankruptcy of Columbia Gas of Massachusetts.
This was the incident. How about the cause?
The NTSB incident report summarized the case in the following
way:
NTSB investigators learned that, until about 4 years ago,
Columbia Gas required that a technician monitor any gas main
revision work which required depressurizing the main. The

5. technician—typically from the Meter and Regulation
department—would use a gauge to monitor the pressure
readings on the impacted main and would communicate directly
with the crew making the change. If a pressure anomaly
occurred, the technician could quickly act to prevent an
overpressurization action. Columbia Gas offered no explanation
as to why this procedure was phased out.
Although the Columbia Gas monitoring center in Columbus,
Ohio, received high-pressure alarms and reported the event to
the Meters and Regulations department two minutes after
receiving the first alarm, there were no technicians prestaged or
positioned to immediately close valves when the
overpressurization occurred. Had Columbia Gas adequately
performed MOC (Management of Change) and placed personnel
at critical points along the system, Columbia Gas could have
immediately addressed the issue and mitigated the consequences
of the event. Therefore, the NTSB recommends that NiSource
apply MOC processes to all changes to adequately identify
system threats that could result in a common mode failure.
Additionally, the NTSB recommends that NiSource develop and
implement control procedures during modifications to gas mains
to mitigate the risks identified during MOC operations. Gas
main pressures should be continually monitored during these
modifications and assets should be placed at critical locations to
immediately shut down the system if abnormal operations are
detected.
NTSB Recommendations
In November 2018, the NTSB issued a series of “urgent” safety
recommendations. The report contained four recommendations
for NiSource, the parent company of Columbia Gas, and one for
the state, seeking elimination of the professional engineer
licensure exemption for public utility work and a requirement
for a professional engineer’s seal on public utility engineering
drawings.

6. The NTSB report recommends NiSource do the following:
· revise the engineering plan and constructibility review process
across all subsidiaries;
· review all records and documentation of natural gas systems;
· apply management of change processes to all changes to
identify threats that could result in a common mode failure;
· develop and implement control procedures during gas main
modifications to mitigate risks.
See below for important references and resources.
References and Resources
NTSB Incident Report
Popular Mechanics article, “The Day The Town Blew Up”
Boston Magazine articleon the real story of the Merrimack
Valley explosions
Fire in the Valley– Podcast – Four episodes
Episode 1: The first minutes of a disaster
Episode 2: “I had never gone toward explosions before”
Episode 3: The sun rises after a disaster
Episode 4: Making the Valley whole again
Page 2 of 2
Phil 1330
Research Paper Assignment

7. .
Length: 1000-1500 words
Format:
· double-spaced WITHOUT an extra line-space between
paragraphs.
· Turabian styled
· footnotes
· 12-point font, standard margins, and page numbers.
· works cited
Instructions for writing Paper:
· This is a research paper. Your job is to research what a
particular moral philosopher would say about a certain
philosophical question.
· Selected one of the ethical questions below and one of the
philosophers below and explain how the philosopher would
answer the question.
· Some philosophers are easier to research than others.
· Some combinations are easier than others. For instance, 9+F
would be much easier to research than 4+L.
· You can choose a philosopher that is not on this list of ancient
white men, but you should consult with me first, because I don’t
want this to be harder for you than it needs to be.
· You must use a minimum of ACADEMIC 3 sources.
· At least 1 primary source
· At least 1 secondary source
· Advice: Students ALWAYS do better on their assignments
when they meet with their professor at least once well before
the paper is due. I have office hours. You should come see me
about your paper during office hours.
· Rubric for Final Paper:
· Is the paper organized, i.e., name, date, class, title, etc.?
· Is there a thesis statement?
· Does the student thoroughly explain the philosophical

8. question?
· Does the student demonstrate thorough knowledge of the
philosopher’s thought?
· Does the body of the paper logically support the thesis
statement?
· Is there a conclusion?
· Are there minimal spelling and grammar errors?
Select one question and one philosopher and describe how
[Letter] would answer the philosophical question [number].
Philosophical Questions:
1. What does it mean to live a good life?
2. Can a society exist without laws?
3. How does someone become a good person?
4. Does moral behavior lead to happiness?
5. Is it ever moral to kill someone rather than let them live?
6. Is suicide always wrong?
7. Should you report your best friend if they commit a crime?
8. How do we decide what is right or wrong in a globalized
world? (Examples of moral issues that hotly contested across
cultures: Child marriages, female circumcision, same-sex
marriage)
9. Is it wrong to legally mandate vaccinations?
10. Are Stop-and-Frisk laws immoral?
Philosophers:
Mild
A. Socrates
B. Plato
C. Aristotle
D. Augustine
E. David Hume

9. F. Jeremy Bentham
G. Immanuel Kant
Spicy
H. Augustine
I. Thomas Aquinas
J. John Locke
K. Thomas Hobbes
L. John Stuart Mill
M. John Rawls
N. G.E.M. Anscombe
Fire
O. Frederick Nietzsche
P. Michel Foucault
ENVISION SUCCESS, TAKE THE JOURNEY, COMPLETE
YOUR DEGREE
The BP Macondo Well Case
Executive Summary

10. The BP deepwater Horizon is one of the worst industrial
catastrophes ever due to the oil rig explosion on April 20, 2010,
in the Gulf of Mexico. Eleven people died in what has become
the worst oil spill in the United States lasting 87 days with 507
million liters of oil spilled in the sea (US Environmental
Protection Agency, 2017). Multiple failing went right up to the
top management of the companies involved and multiple points
at which it could have been averted. In this report we addressed
three of their major issues:
· BP’s safety culture
· BP’s risk-seeking culture
· The lack of ethics values
Issues will be identified then practical solutions to these issues
will be presented. Finally, recommendations will be made based
on the pros and cons of each solution and thanks to the solution
ranking matrix.
Background
The BP deepwater Horizon is one of the worst industrial
catastrophes ever due to the oil rig explosion on April 20, 2010,
in the Gulf of Mexico. Eleven people died in what has become
the worst oil spill in the United States lasting 87 days with 507
million liters of oil spilled in the sea (US Environmental
Protection Agency, 2017).
A single cause is not at the origin of the tragedy of the Macondo
well. It is rather a ‘collection’ of errors that led to the explosion
and the fire of the platform. The leak was indisputably caused
by technical failures, but those –in turn - could have been
avoided or at least lessened in impact and probability if they
had not had deeper organizational and systemic failures within
BP. The US Federal investigation identified the technical
failures that led to the blow out, it includes: the cement failing
to seal the bottom of the well, lack of centralizers in order to

11. center the pipe when pouring the cement, the blowout preventer
malfunction, the high pressure in the drill and the cement
formula that was not certified to function properly, etc.
However, multiple failure causes, in this author’s opinion, are
traceable to project management issues, which in turn can be
linked to the top management of the companies involved and
multiple points at which it could have been averted. The three
top issues that we can identify are BP’s safety culture, BP’s
risk-seeking culture and the lack of ethics values.
I will discuss three major project issues that have been
identified within the “BP and the Deepwater Horizon Disaster
of 2010” that led up to the explosion and oil spill.
Solution
s and their pros and cons will then be introduced along with
recommendations of how the disaster could have been avoided.
Issues Identification
Issue 1
The first issue and the most important concerns BP’s safety
culture. In fact, despite the fact that BP had publicly declared
its commitment for safety, BP had multiple issues with safety
breaches. In a previous accident in BP’s Texas City refinery
which killed 15 persons, the investigation report that they

12. purposely cut back the maintenance and safety measures in
order to limit costs.
Even after trying to improve personal safety, BP misunderstood
that by decreasing and having a lower personal injury rates do
not mean that safety process is well implemented. According to
Ingersoll C. and al. (2012) U.S. refinery workforce believe that
process safety is not a core value at BP. Meaning that in BP the
workforce is not able to perceive a clear corporate message
coming from BP’s executive.
In BP’s 18 values, only one concerns health and safety, it
claims: “no accidents, no harm to people, and no harm to the
environment” But nothing clear is stated concerning safety
process and it has never been a real commitment for BP. They
never tried to implement new safety policies and processes, it
has been seen more as a way to communicate and articulate a
“safety” message to maintain a respectable corporate image than
a real way to establish long-term change into their safety
process.
Issue 2

13. The second issue is BP’s corporate risk management appetite
which is very risk-seeking. It has been stated that BP's culture
is one that values doing as much as they can for a minimum
budget. It was expected that the Macondo well project had a
budget of $96.2 billion and was scheduled to take place in 51
days. In addition, the well started to be functional in January of
2010 and the explosion occurred in April, so less than 3 months
after the effort began.
Indeed, the project was six weeks behind schedule and $58
million over budget (National Commission on the BP Deepwater
Horizon Oil Spill and Offshore Drilling, 2011), with such time
and cost constraints we can surely imagine that decisions had
been made in alacrity.
Moreover, with the technical issues that happen previously the
blowout of Deep-Water Horizon, we can affirm that with a
proper risk management it would have unquestionably reduced,
if not eliminated, the probability of the blowout. In the
conclusion stated in the National Commission's report (2011),
the explosive loss of the Macondo well could have been
prevented. In fact, decisions made before and during the
disaster were never subject to an official risk assessment.

14. Furthermore, BP was conscious that they needed to provide
maintenance to their machinery in order to be in compliance.
Indeed, a week before the accident, the blowout preventer
(BOP) was accidentally deteriorating (Greene-Blose, 2015). As
an example, one of the censors of the control pod was not
working due to an emptied battery and the other was not
working due to a defective solenoid valve (National
Commission, 2011). In fact, no one in the Deepwater horizon
workforce and executive took the necessary actions to solve this
problem. According to Hillson R. & Webster M. (2005) what
characterizes risk seekers’ is that they tend to downplay threats.
One week prior to the blowout, the project team had actually
failed to identify risk triggers resulting in an extreme threat.
Consequently, both the probability and impact of this risk has
become more important, it is then too late for preventive action,
the risk is accepted.
Issue 3
The third issue concerns the lack of ethics in BP’s core values..
Or at least the conveyance of those values to project team
members. According to Jennings M. (2010): “BP's management
principles, business plans, and codes of ethics focused on safety

15. and compliance, [but] something was
lost in translation between words and actions. The message in
the written materials was not the message that the employees
heard or followed.
There was a long-standing cultural disconnect between outward
appearances and internal behaviors.” In fact, corporate ethics
were sacrificed when it came to catch up their delay.
Moreover, Mr. Reilly, the former president of the United States
environmental protection agency, denounced "a culture of
complacency" among BP corporations, resulting in "bad
decisions" as they were preparing to complete the drilling of the
"Macondo" well at 1,500 meters below the sea surface. In fact,
there has been precipitation in the realization of the well
because on site asset managers were rushing in order to meet
performance targets. Furthermore, they extended this practice
among all employees working on the site, so employee
compensation was tied to asset performance and the overall
performance of the site. We can easily imagine how this manner
to behave can impact the project quality and push employees to
question the respect of ethics.
Leadership responsibility, which is receiving more attention,

16. has been widely discussed in the context of large corporations
that are suffering the consequences of their actions (or
inaction). Managers are often accused of acting selfishly and
sacrificing the company's bottom line for their own benefit.
Already in the 1970s, Jensen and Meckling (1976) were
suggested ways to counter such behavior or to encourage
managers to act in the interest of the company and the society.
In a general way, the CEO needs to enhance shareholder value,
in line with the expectations of the shareholders and,
respectively, the management committee. However, what we do
not know is how it is supposed to achieve that goal, that is to
say, what risks he must take. The CEO must therefore improve
the security aspect so as to minimize operational risks and limit
potential liabilities. In the case of BP, during the trial, Tony
Hayward emphasized the $14 billion invested in security since
his appointment as CEO, but he was not able to say how it was
spent. That’s why it is important spending
the time needed in order to investigate even the most minor
failure and then implementing the appropriate changes.
Proposed